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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208958
Report Date: 08/09/2022
Date Signed: 08/09/2022 02:17:01 PM


Document Has Been Signed on 08/09/2022 02:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:VISALIA SENIOR LIVING CAREFACILITY NUMBER:
547208958
ADMINISTRATOR:RAMOS, ANGELAFACILITY TYPE:
740
ADDRESS:310 EAST ROBIN AVETELEPHONE:
(559) 747-2182
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:6CENSUS: 3DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Administrator Angela RamosTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst LPA Shawna Doucette and Vadim Gorban conducted an Annual Infection Inspection on this date. LPA was met by Staff Rosie Corrales and discussed the purpose of the visit. Administrator Angela Ramos responded to the facility to assist with the inspection. LPA and Administrator Angela Ramos began the tour at the front entrance/office of the facility.

During tour of the facility LPA's observed the garage to be turned into a staff room. LPA's observed R1 to have full bed rails without a physicians note.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Covid-19 related signs were observed in the common areas.

Cleaning supplies were observed locked in cabinet in the garage. LPA observed the following personal protective equipment in garage; gowns, gloves, face shields, hand sanitizer and masks. LPA observed all facility staff to be wearing masks upon arrival.

Resident’s files have updated emergency contact information. LPA's reviewed staff training for Covid.

Refer to 809d.


Exit interview was conducted and a copy of this report was provided
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/09/2022 02:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: VISALIA SENIOR LIVING CARE
FACILITY NUMBER: 547208958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by converting garage into a staff room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2022
Plan of Correction
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Plan of Correction POC Licensee agrees to submit fire clearance by POC due date 8/31/22
Type A
Section Cited
CCR
87608(5)(B)
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by R1 having full bedrails without a physicians note, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2022
Plan of Correction
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Plan of Correction POC Licensee agrees to submit a doctors note for R1 to have bedrails by POC due date 8/31/22

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2